RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD-2017-03062
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Combat Engineer, medically separated “rhabdomyolysis” with a disability rating of 0%.   

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20060126	VARD - 20061130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rhabdomyolysis	7999-7900	0%	Renal Insufficiency, Hypertension, Urinary Incontinence, Cardiohypertrophy 	7020-7541	60%	20060627	
Elevated Creatinine	Not Unfitting					
Urge Incontinence	Not Unfitting 					
Hypoparathyroidism	Not Unfitting	Hypoparathyroidism	7905	10%	20060627	
Status-Post Bilateral Carpal Tunnel Release	Not Unfitting	Carpal Tunnel Syndrome and Ulnar Tunnel, Right Wrist, Status Post Surgery	8515	NSC	20060614	
		Carpal Tunnel Syndrome, Left Wrist	8515	NSC	20060614	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Rhabdomyolysis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s rhabdomyolysis (muscle tissue breakdown) began shortly after being activated for active duty in July 2004 when he received multiple vaccinations (anthrax, hepatitis B, hepatitis A, IPV (inactivated polio vaccine), MGC (meningitis vaccine), TD (tetanus-diphtheria), and typhoid) and  a PPD (tuberculosis skin test).  Approximately 5 days later, he became acutely ill with chest and diffuse muscle pain, and was unable to move without pain.  He thought he was having a heart attack and was hospitalized and underwent an extensive cardiology work-up.  After detailed evaluations found ischemia of the anterior wall of the heart and elevated creatinine (measurement of renal status) and creatine kinase (CPK), he was diagnosed with rhabdomyolysis.  

He was admitted to the hospital again in January 2005 and July 2005 for elevated CPK levels, and continued to have evidence of muscle pain, weakness, and an inability to move well along with generalized myalgias and arthralgias.  In the interim, he saw a civilian rheumatologist and was diagnosed with autoimmune polymyositis. Treatment consisted of Imuran (immunosuppressive medication) and prednisone (steroid).  He continued to have weakness and muscle twitching, and a record  review revealed a history of low calcium.  Further studies confirmed hypoparathyroidism (see below) with a history of low calcium and surgeries for carpal tunnel spasms.  Treatment with calcium and Rocaltrol (synthetic Vitamin D) was instituted and the carpopedal spasms and muscle twitching improved.  The prednisone was tapered, the Imuran discontinued, and creatinine and creatine kinase levels decreased with time.  

During the 4 February 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 12 months prior to separation, physical examination revealed blood pressures of 163/87 and 151/90 and a pulse of 69 beats/minute.  The MEB NARSUM examination the same day noted complaints of elevated creatine kinase and probable rhabdomyolysis, but physical examination was unremarkable.  On 14 September 2005, the CI was admitted to the hospital after presenting with chest wall pain and fatigue.  The 1 December 2005 MEB NARSUM examination, less than 3 months prior to separation, noted complaints of a history of presumptive rhabdomyolysis and hypoparathyroidism.  Physical examination showed a muscular, alert, pleasant male in no acute distress.  The remainder of the examination was unremarkable.  

At the 27 June 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported medical problems including hypoparathyroidism, renal insufficiency, and rhabdomyolysis.  Physical examination showed blood pressures at 163/84, 184/75, and 151/81, and a pulse of 65 beats/minute.  The remainder of the examination was unremarkable.  The CI was admitted to the hospital in July 2007 for a recurrent episode of rhabdomyolysis.  At several follow-up visits, he had tenderness and weakness of the upper arm muscles. Thyroid stimulating hormone was 0.61 uU/ml (normal 0.46-4.98) and free T4 was 0.86 ng/dL (normal 0.7-1.48 ng/dL).  The CI’s family physician indicated in a memo on 22 August 2006 that he had polymyositis and was currently disabled.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the rhabdomyolysis 0%, analogously coded 7999-7900 (hyperthyroidism), citing elevated creatine kinase and normal renal function.  The VA rated the renal insufficiency, hypertension, urinary incontinence, cardiac hypertrophy, and anterior wall defect due rhabdomyolysis 60%, analogously coded 7020-7541 (cardiomyopathy-renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease processes), based on the C&P examination, citing a decrease in kidney function with a creatinine of 1.8 mg/dL (normal 0.6-1.3).  Panel members noted the PEB used analogous code 7999-7900, although the CI did not have hyperthyroidism.  While there is no distinct VASRD code for rhabdomyolysis, the panel agreed that use of analogous code 5099-5025 (fibrositis, primary fibromyalgia syndrome) was appropriate in this case since the CI had widespread muscle pain and tenderness.  His symptoms were episodic with exacerbations, often precipitated by overexertion, and present more than one-third of the time, which warrants a 20% rating.  Although he had frequent exacerbations symptoms, the panel did not find them to be constant, or nearly so, and refractory to therapy for a higher 40% rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the rhabdomyolysis, coded 5099-5025.  

Contended PEB Conditions:  Elevated Creatinine, Urge Incontinence, Hypoparathyroidism, and Status Post Bilateral Carpal Tunnel Release.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards. 
There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the rhabdomyolysis, the panel recommends a disability rating of 20%, coded 5099-5025 IAW VASRD §4.71a.  In the matter of the contended elevated creatinine, urge incontinence, hypoparathyroidism, and status post bilateral carpal tunnel release conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Rhabdomyolysis	5099-5025	20%	

The following documentary evidence was considered:

[AR NUMBER], XXXXXXXXXXXXXX

Dear XXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Enclosure